“Do patients ever keep secrets from their physicians? Do they ever lie?”
These are just two of many questions I've prepared for a guest lecture to an undergraduate ethics class. While most academic discussions focus on physicians' professional obligation to maintain confidentiality (except when life or limb is at stake), I want to explore the patient dynamics.
I've lumped together secrets and lies because the fundamental problem is the same: For whatever reason, patients keep some fact(s) to themselves or distort a truth.
As a medical student, I was introduced to secrets and lies as obstacles to ideal patient care. My mentors taught me how patients' past experiences and beliefs can affect what patients say. These professors kept hammering into me that the key to proper diagnoses and treatments is taking a thorough and accurate history. So I strove to perfect my delivery of open-ended, non-judgmental questions and thus facilitate wide-open communication.
By the time I hung my shiny new shingle outside Suite 508, I was adept at using the same tone of voice whether asking patients “How many cups of coffee and/or tea do you drink daily?” or “How many men and/or women do you sleep with?” I asked patients the names of all the prescription, over-the-counter, alternative, and illicit drugs they used. I provided spaces to record the number of spontaneous and therapeutic abortions as well as live- and stillbirths.
Normalizing sensitive information paved the way for full disclosure. Or so I naively thought. One day a chart with the results of a new patient's screening blood work was placed on my desk. The delightful octogenarian I'd met the day before had a positive VDRL. Only after her old records finally arrived did I learn she'd already been adequately treated for both latent and neurosyphilis. Twice.
After telling the students this anecdote and describing my shock, I can recite a cynical aphorism from internship days: “Whatever patients say, multiply the number of cigarettes by two and ounces of alcohol by four.” Then I can jump-start the class discussion with a provocative question: “Won't pervasive skepticism risk destroying the mutual trust necessary for optimal care?”
Since effective solutions begin with understanding the problem, I'll prompt the students: “Why might patients lie?” I can share stories about patients who lie to keep up the “good patient” image or to escape being admonished for not complying with physical therapy or a low-salt diet. Or about patients who falsely deny having a seizure, so their doctors won't take away their car keys again. And sadly, about patients who insist they are doing fine, covering up their misery from the side effects of salvage therapy out of fear their doctors will give up on them.
If the ethics class needs some zing, I can relate my own stupid blunder. For idiotic reasons that somehow made sense to me in the hurricane of first-remission emotions, I chose to take a medication incorrectly, instead of discussing my concerns with my physician. When a new symptom popped up, I felt obligated to confess. I can paint a picture for the students of how my face flushed with embarrassment and shame, feelings that lingered for years.
Under certain circumstances and for a variety of reasons, patients can be afraid to tell the truth. Some patients practice their deception for days, while others are surprised by an answer that escapes their lips at a doctor visit. Whether deliberate or subconscious, these deceptions reflect patients whose fear of the truth overwhelms their desire to help their situation by providing an accurate history—even if the fear lasts only momentarily.
Note that sometimes patients' fears have nothing whatsoever to do with their physicians. Talking about a particular topic to anyone stirs patients' painful feelings of embarrassment or shame, or regret-filled distress about past choices. So even when patients want their physicians in on their secret and trust their physicians to react with gracious understanding, they still may clam up out of fear they'll be asked about it or offered sympathy, either of which they couldn't handle now.
What's an oncologist to do? For starters, when you suspect something might be awry, invite patients to share any secrets or something they said “that may have come out wrong.” Help patients save face by offering something like, “Lapses happen. Patients are just trying to make things work out okay when they are afraid to tell the truth.”
Then you can help them overcome their fear by focusing on the shared mission. “I need to know everything—the good and the bad, the silly and the embarrassing—to do all I can to take good care of you.” And since friends sometimes keep secrets to prevent hurt feelings or other problems, acknowledging and then moving away from any such camaraderie may help, too: “We've become friends over the years, and this is great. But when dealing with medical issues, our relationship has to be professional, not social.”
Patients may relax if they know you won't scold or pry. “You said you drink three beers a day. If the number is really six, I just need to know that to help me make the right diagnoses and prescribe the right treatments. We don't have to talk about your drinking.”
Secrets and lies are more than problems to solve. They are opportunities for healing.
In some cases, a physician's quiet listening to a painful secret is the best cure of all. Physicians who respond without anger, frustration or disappointment spare their patients from additional feelings of vulnerability and loss of control, feelings that may have prompted the lies in the first place.
Whatever the case, the truth can set patients and their physicians free. Together, physicians and patients can move forward toward the best possible solutions.
